employment

Faculty Loan Repayment Program (FLRP)

Intent of Employment

The _________________________________________________________ intends to employ

Institution

_________________________________________________________ in a faculty position

Applicant

(duties primarily consist of teaching) for a minimum of 2 years (August 1, 2006 – July 31, 2008). The position is full-time ____ or part-time ____ (must check one).

The institution is accredited by ___________________________________________________.

The institution agrees to (must check one):

----- make payments of principal and interest in an amount equal to the

amount of such quarterly payments made by the HHS Secretary.

These payments will be in addition to the applicant’s faculty salary.

OR

----- request a waiver of its share of cost. (The Secretary may waive

the requirement if the Secretary determines it will impose an

undue financial hardship on the school.) The institution must

provide supporting documentation such as audit report, budget

report, etc.

Name: ________________________________________ Date: ______ / ______ / ______

Title: __________________________________________

Address: ________________________________________

________________________________________

Phone: _______ - _______ - _________ ex _________

Fax : _______ - _______ - _________

E-mail: _________________________________________

ANY PERSON WHO KNOWINGLY MAKES A FALSE STATEMENT OR MISREPRESENTATION ON THIS FORM IS SUBJECT TO PENALTIES WHICH

MAY INCLUDE FINES AND IMPRISONMENT UNDER FEDERAL STATUTE.